Citi Benefits Handbook
You can use an out-of-network provider for medical services and still be reimbursed under the CP500. These expenses generally are reimbursed at a lower level than in-network expenses, after you have met the out-of-network deductible.
For information about how to file a claim for out-of-network services or appeal a denied claim, see "Claims and Appeals for Aetna Medical Plans", or "Claims and Appeals for Anthem BlueCross BlueShield Medical Plan."
Deductible and Coinsurance
If you elect to use physicians or other providers outside the network, you will need to meet an annual deductible of $1,500 individual/$3,000 family maximum before any benefit will be paid. Once you meet your deductible, you must submit a claim form accompanied by your itemized bill to be reimbursed for covered expenses.
The individual deductibles apply to all covered expenses except routine preventive care (which is covered at 100% in network) and must be met each calendar year before any benefits will be paid.
The family deductibles represent the most a family will have to pay in individual deductibles in any calendar year. Only covered expenses that count toward your or your dependent's individual deductible can be applied toward the family deductible. The family deductible can be met as follows:
- Two in a family: Each member must meet the $500 in-network/$1,500 out-of-network individual deductible; or
- Three or more in a family: Expenses can be combined to meet the $1,000 in-network/$3,000 out-of-network family deductible, but no one person can apply more than the individual deductible ($500/$1,500) toward the family deductible amount.
Once you have met the deductible, CP500 normally pays 60% of the maximum allowed amount (MAA) for covered expenses that are received out of network. Providers may balance-bill you for the charges above MAA, and you are responsible for those charges.
Medical Out-of-Pocket Maximum
The out-of-pocket maximum for medical services rendered outside of the network is $6,000 individual/$12,000 family. This amount includes the $1,500 individual/$3,000 family deductible, coinsurance and copays, and represents the most you will have to pay out of your own pocket in a calendar year for medical services received outside the network, excluding charges that exceed MAA expenses, penalties, prescription drug expenses or services not covered under CP500. Once this out-of-pocket maximum is met, covered expenses are payable at 100% of MAA for the remainder of the calendar year.
Eligible expenses within a family can be combined to meet the family out-of-pocket maximum, but no one person can apply more than the individual out-of-pocket maximum amount of $6,000 to the family out-of-pocket maximum of $12,000.
Not all expenses count toward your medical out-of-pocket maximum. Among those that do not count are:
- Expenses that exceed MAA;
- Prescription drug expenses (which apply toward a separate prescription drug out-of-pocket maximum); and
- Charges for services not covered under the plan.
To help you manage the high cost of prescription drugs, there is also a separate annual prescription drug out-of-pocket maximum. Once you reach the prescription drug out-of-pocket maximum of $1,500 individual/ $3,000 family, the plan pays the full cost of prescription drug expenses for the remainder of the plan year.
In addition, expenses incurred when using in-network services count toward your out-of-network, out-of-pocket maximum.
Each participant has a $250 annual credit toward all out-of-network wellness services. Thereafter, covered expenses are not subject to the deductible, and expenses that exceed the $250 credit are covered at 60% of MAA. Preventive care services include:
- Routine physical exams: Well-child care and adult care, performed by the patient's PCP at a frequency based on American Medical Association guidelines. For frequency guidelines, contact your Claims Administrator;
- Routine diagnostic tests — for example, CBC (complete blood count), cholesterol blood test, urinalysis;
- Well-child services and routine pediatric care; and
- Routine well-woman exams.
The CP500 offers coverage for routine care services to help in the early detection of health problems.
- Routine vision exam: Covered at 100%, not subject to deductible, one exam per calendar year, performed by an in-network ophthalmologist or optometrist; and
- Routine hearing exam: Covered at 100%, not subject to deductible, one exam per calendar year, performed by an in-network otolaryngologist or otologist.
Hospital care (inpatient and outpatient) will be reimbursed at 60% of MAA, after you meet your annual deductible. Coverage for room and board is limited to expenses for the regular daily charge made by the hospital for a semiprivate room (or private room, when medically appropriate or if it is the only room type available). Precertification of an inpatient admission is required. Precertification is required for certain outpatient procedures and services.
Services provided in a hospital emergency room from an out-of-network provider are covered at 80% of MAA for covered services after the deductible has been met.
Aetna: When emergency care is necessary, please follow the guidelines below:
- Seek the nearest emergency room, or dial 911 or your local emergency response service for medical and ambulatory assistance. If possible, call your physician, provided a delay would not be detrimental to your health.
- After assessing and stabilizing your condition, the emergency room should contact your physician to obtain your medical history to assist the emergency physician in your treatment.
- If you are admitted to an inpatient facility, notify your physician as soon as reasonably possible.
- If you seek care in an emergency room for a non-emergency condition, the plan will not cover the expenses you incur.
Services provided by an urgent care center are covered at 80% for covered services after the deductible has been met.
Aetna: Call your PCP if you think you need urgent care. You may contact any physician or urgent care provider, in or out of network, for an urgent care condition if you cannot reach your physician. If it is not feasible to contact your physician, please do so as soon as possible after urgent care is provided. In-network providers are required to provide urgent care coverage 24 hours a day, including weekends and holidays. If you need help finding an urgent care provider, you may call Member Services at the toll-free number on your ID card, or you may access Aetna's online provider directory at www.aetna.com. Follow-up care is not considered an emergency or urgent condition and is not covered as part of any emergency or urgent care visit. Once you have been treated and discharged, you should contact your physician for any necessary follow-up care.
Multiple Surgical Procedure Guidelines
If you are using an out-of-network provider for a surgical procedure, the following multiple surgical procedure guidelines will apply.
If more than one procedure will be performed during one operation — through the same incision or operative field — the plan will pay according to the following guidelines:
- First procedure: The plan will allow 100% of the negotiated or MAA.
- Second procedure: The plan will allow 50% of the negotiated or MAA.
- Additional procedures: The plan will allow 50% of the negotiated or MAA for each additional procedure.
- Bilateral and separate operative areas: The plan will allow 100% of the negotiated or MAA for the primary procedure, 50% of the secondary procedure, and 50% of the negotiated or MAA for tertiary/additional procedures.
If billed separately, incidental surgeries will not be covered. An incidental surgery is a procedure performed at the same time as a primary procedure and requires few additional physician resources and/or is clinically an integral part of the performance of the primary procedure.